Dissolution of arterial plaque

ABSTRACT

Embodiments of methods of treating atherosclerosis are described. In some embodiments an emulsifier is provided to achieve levels in the systemic circulation that are effective to solubilize atherosclerotic plaque, resulting in plaque regression. In some embodiments, levels of greater than 50 μM are achieved; in some embodiments levels ranging from about 100 μM to about 600 μM are achieved; in some embodiments, levels ranging from about 100 μM to about 300 μM are achieved. Emulsifiers can include bile salts, saponins, and ionic, nonionic, and zwitterionic detergents, or salts, conjugates, hydrates, solvates, or polymorphs thereof. In some embodiments, a statin can be administered simultaneously or sequentially with an emulsifier.

RELATED APPLICATIONS

This application is a continuation-in-part of U.S. application Ser. No.11/649,062, filed Jan. 3, 2007, entitled “Dissolution of ArterialCholesterol Plaques by Pharmacological Preparation,” which is acontinuation-in-part of U.S. application Ser. No. 11/384,150, filed Mar.17, 2006, entitled “Dissolution of Arterial Cholesterol Plaques byPharmacological Preparation,” which is a continuation-in-part of U.S.application Ser. No. 11/373,943, filed Mar. 13, 2006, entitled“Dissolution of Arterial Cholesterol Plaques by PharmacologicalPreparation,” which claims priority to U.S. Provisional Application No.60/739,143, filed Nov. 22, 2006, entitled “Dissolution of ArterialCholesterol Plaques by Pharmacological Preparation”; this application isalso a continuation-in-part of U.S. application Ser. No. 11/542,694,filed Oct. 4, 2006, entitled “Dissolution of Arterial CholesterolPlaques by Phytochemical Emulsifiers,” which claims priority to U.S.Provisional Application No. 60/793,379, filed Apr. 19, 2006, entitled“Dissolution of Arterial Cholesterol Plaques by PhytochemicalEmulsifiers”; this application also claims priority to U.S. ProvisionalApplication No. 60/930,410, filed May 15, 2007, entitled “Dissolution ofArterial Cholesterol Plaques by Pharmacologically Induced Elevation ofEndogenous Biliary Salts”; this application is also acontinuation-in-part of International Application No. PCT/US2006/044619,filed Nov. 16, 2006, entitled “Dissolution of Arterial CholesterolPlaques by a Class of Pharmacological Compounds,” which claims priorityto U.S. patent application Ser. No. 11/384,150, filed Mar. 17, 2006,U.S. patent application Ser. No. 11/373,943, filed Mar. 13, 2006, andU.S. Provisional Application No. 60/739,143, filed Nov. 22, 2005; thisapplication is also a continuation-in-part of International ApplicationNo. PCT/US2007/001214, filed Jan. 16, 2007, entitled “Drug-Eluting Stentwith Atherosclerotic Plaques Dissolving Pharmacological Preparation,”which claims priority to U.S. Provisional Application No. 60/760,471,filed Jan. 20, 2006, entitled “Drug-Eluting Stent with AtheroscleroticPlaque Dissolving Pharmacological Preparation”; the contents of all ofthe foregoing are hereby incorporated by reference herein in theirentireties.

FIELD OF THE INVENTIONS

Embodiments described herein relate to pharmaceutical formulationscomprising emulsifiers, for example, bile acids, detergents, andsaponins, and pharmaceutically acceptable salts or conjugates ofemulsifiers, and their use in the treatment of atherosclerosis, inparticular the use of such pharmaceutical formulations to dissolve thelipid core of plaques to result in plaque regression.

BACKGROUND OF THE INVENTIONS

Cardiovascular disease is a leading cause of death in the humanpopulation. This is especially true in developed countries, where theincreasing incidence of obesity is considered to be the majorcontributing factor to cardiovascular and related diseases. For example,the incidence of heart disease as a cause of death was 12.4% in allWorld Health Organization States, whereas in the U.S., heart attacksaccount for nearly 30% of deaths. In addition, other disease statesrelated to or exacerbated by impairment of cardiovascular function makecardiovascular diseases the single greatest contributor to death anddisability.

The underlying issue in cardiovascular disease is the development ofatherosclerosis, a disease that affects vessels of the arterialcirculation. It is characterized as a chronic inflammatory response inthe walls of blood vessels, in part due to deposition of lipoproteins,in particular low density lipoproteins (LDLs), as well as infiltrationby macrophages. Atherosclerosis is known to begin early in life (duringchildhood) with the rate of progression dependent on a variety offactors including diet, exercise, and genetic predisposition.

The earliest morphologically identifiable stage of plaque development istermed a fatty streak, which in fact is an accumulation of macrophagesthat have ingested oxidized LDL in the vessel wall, giving them theappearance of fat in the muscular tissue that forms the vessel wall.These macrophages ingest oxidized LDL in the plaque, accumulatingnumerous cytoplasmic vesicles—these macrophages become known as foamcells. Over time the fatty streak evolves to become an establishedplaque characterized by further accumulation of macrophages and thelocal accumulation of an inflammatory infiltrate. Eventually foam cellsdie, releasing their contents into the plaque, which further exacerbatesthe inflammatory reaction. In addition, cytokines released by damagedendothelial cells lead to smooth muscle proliferation and migration fromthe vessel media to the intima, leading to the development of a fibrouscapsule that covers the plaque. Over time, calcification at the marginsof the plaque can occur.

It has been known for some time that over time that progressiveenlargement of atherosclerotic plaques eventually leads to a narrowingof the lumen of afflicted vessels. Traditionally, narrowing of 75% orgreater has been considered clinically significant. However, morerecently it has been discovered that events such as heart attacks canoccur even when there is no sign of significant narrowing of vessels,due to the inherent instability of some plaques.

It is now known that plaques can be structurally unstable, andspontaneously rupture. When a plaque ruptures, tissue fragments andplaque contents are released into the lumen of the blood vessel,resulting in a clotting response. While the clot is effective to coverand stabilize the rupture, it intrudes into the lumen of the vessel,reducing luminal diameter, and obstructing blood flow, thus creating astenotic region. If the compromise to flow is significant, for examplewhere the clot completely or nearly completely occludes the lumen,ischemia can occur in tissues downs stream from the site of theblockage. Where the vessel is a coronary artery, this can lead to amyocardial infarction. Should the blockage occur in a cerebral arterystroke is possible. Significantly, the majority of fatal events occurfrom ruptures in areas where there is little prior narrowing, althoughit is recognized that over time repeated ruptures of plaques will leadto stenosis, and eventually downstream ischemia, with the same clinicaloutcome.

Because of the risk posed by unstable plaque, there is now a recognizedneed to detect atherosclerotic plaque, and in particular soft, orvulnerable plaque, prior to the patient becoming symptomatic. Earlierdetection of vulnerable plaque can be especially useful in order tobegin a course of treatment that can reduce the risk of a suddenischemic event due to plaque rupture, or due to the gradual developmentof stenotic regions in a vessel as can occur over time, or to reopenareas of vessel that have become substantially occluded. Typically,treatment of stenosis in sensitive areas such as the heart or the brainhas been accomplished by angioplasty techniques. Maintaining patency ofvessels has become easier with the advent of vascular stent devices.

In the past, detection and diagnosis of atherosclerosis has beendifficult. For example, according to data in the U.S. from 2004, thefirst symptom of cardiovascular disease in over half of those sodiagnosed, is heart attack or sudden death. Unfortunately, by the timeobvious symptoms arose, the disease is usually quite advanced with theresult that treatment options and clinical outcome can be limited. Therecognition of contributing factors such as the effect of cholesterolintake, obesity, and smoking, has led to an awareness of the benefit ofpreventative lifestyle choices in reducing the risk of developingatherosclerosis.

More recently, advances have also been made in both the diagnosis andtreatment of cardiovascular disease. For example, 64 slice CT technologynow makes it possible to evaluate the extent cardiovascular diseasethrough detection of calcifications in vessels. In addition, CTprotocols are also available that make it possible to visualizevulnerable plaque. Thus, it is becoming easier to detect atherosclerosisat earlier and earlier stages, providing an ever increasing window ofopportunity to treat the disease at as early a stage as possible.

SUMMARY OF THE INVENTIONS

While prior art treatments can be effective to deal with some of thefactors that contribute to the development of atherosclerotic plaque(e.g., use of statins to reduce cholesterol levels), or to open occludevessel (e.g., angioplasty and vascular stents) there remains a need foreffective ways in which to effect regression of existing plaques inorder to decrease plaque burden in patients.

Accordingly, in some embodiments there is provided, a method, oftreating atherosclerosis in a patient, comprising: administering, acrossan epithelium of a patient, a pharmaceutical formulation comprising anemulsifier; enhancing a permeability of the epithelium to the emulsifierwith a permeability enhancer; wherein enhancing the permeability of theepithelium is effective to result in passage of the emulsifier acrossthe epithelium and into the patient's systemic circulation; wherein thepassage of the emulsifier across the epithelium results in sustainedlevels of the emulsifier in the patient's systemic circulation that aretherapeutically effective to result in regression of an atheroscleroticplaque.

In some embodiments, the emulsifier comprises at least one of a bileacid, a saponin, a detergent, or pharmaceutically acceptable salts,conjugates, hydrates, solvates, polymorphs, or mixtures thereof. In someembodiments, the emulsifier comprises a bile acid, or pharmaceuticallyacceptable salts, conjugates, hydrates, solvates, polymorphs, ormixtures thereof.

In some embodiments, the sustained levels of the emulsifier in thesystemic circulation are greater than 50 μM. In some embodiments, thesustained levels of the emulsifier in the systemic circulation are in arange between about 50 μM and about 600 μM. In some embodiments, thesustained levels of the emulsifier in the systemic circulation are in arange between about 100 μM and about 300 μM.

In some embodiments, the emulsifier comprises deoxycholic acid.

In some embodiments, the sustained levels of the deoxycholic acid in thesystemic circulation are greater than 50 μM. In some embodiments, thesustained levels of the deoxycholic acid in the systemic circulation arein a range between about 50 μM and about 600 μM. In some embodiments,the sustained levels of the deoxycholic acid in the systemic circulationare in a range between about 100 μM and about 300 μM.

In some embodiments, the emulsifier comprises a mixture ofursodeoxycholic acid and deoxycholic acid in substantially equimolaramounts. In some embodiments, the emulsifier comprises hyodeoxycholicacid. In some embodiments, the sustained levels of the hyodeoxycholicacid in the systemic circulation are greater than about 50 uM. In someembodiments, the sustained levels of the hyodeoxycholic acid in thesystemic circulation are in a range from about 50 uM to about 600 uM. Insome embodiments, the sustained levels of the hyodeoxycholic acid in thesystemic circulation are in a range from about 100 uM to about 300 uM.

In some embodiments, the permeability enhancer comprises at least one ofa non-ionic detergent, an ionic detergent, and a zwitterionic detergent.In some embodiments, the permeability enhancer comprises at least one ofiontophoresis, electroporation, sonophoresis, thermal poration,microneedle treatment, and dermabrasion.

In some embodiments, the pharmaceutical formation is administeredintravenously. In some embodiments, the pharmaceutical formation isadministered intra-arterially. In some embodiments, the pharmaceuticalformation is administered orally. In some embodiments, thepharmaceutical formation is administered sublingually. In someembodiments, the pharmaceutical formation is administered transdermally.In some embodiments, the pharmaceutical formation is administered via animplantable device. In some embodiments, the pharmaceutical formation isadministered by injection. In some embodiments, the pharmaceuticalformation is administered transmucosally.

In some embodiments, the method further comprises administering a statineither simultaneously or sequentially with the pharmaceuticalformulation. In some embodiments, the pharmaceutical formulation furthercomprises the statin.

In some embodiments, there is provided a method of treatingatherosclerosis in a patient comprising: administering a pharmaceuticalformulation comprising an emulsifier in an amount effective achieve aconcentration of the emulsifier in the systemic circulation of at least50 μM; wherein the concentration of the emulsifier in the systemiccirculation is sustained for a period of at least two hours; wherein theconcentration of the emulsifier is effective to result in regression ofan atherosclerotic plaque.

In some embodiments, the emulsifier comprises at least one of a bileacid, a saponin, a detergent, or pharmaceutically acceptable salts,conjugates, hydrates, solvates, polymorphs, or mixtures thereof. In someembodiments, the emulsifier comprises a bile acid, or pharmaceuticallyacceptable salts, conjugates, hydrates, solvates, polymorphs, ormixtures thereof.

In some embodiments, the sustained levels of the emulsifier in thesystemic circulation are greater than 50 μM. In some embodiments, thesustained levels of the emulsifier in the systemic circulation are in arange between about 50 μM and about 600 μM. In some embodiments, thesustained levels of the emulsifier in the systemic circulation are in arange between about 100 μM and about 300 μM.

In some embodiments, the emulsifier comprises deoxycholic acid. In someembodiments, the sustained levels of the deoxycholic acid in thesystemic circulation are greater than 50 μM. In some embodiments, thesustained levels of the deoxycholic acid in the systemic circulation arein a range between about 50 μM and about 600 μM. In some embodiments,the sustained levels of the deoxycholic acid in the systemic circulationare in a range between about 100 μM and about 300 μM.

In some embodiments, the emulsifier comprises a mixture ofursodeoxycholic acid and deoxycholic acid in substantially equimolaramounts.

In some embodiments, the emulsifier comprises hyodeoxycholic acid. Insome embodiments, the sustained levels of the hyodeoxycholic acid in thesystemic circulation are greater than about 50 uM. In some embodiments,the sustained levels of the hyodeoxycholic acid in the systemiccirculation are in a range from about 50 uM to about 600 uM. In someembodiments, the sustained levels of the hyodeoxycholic acid in thesystemic circulation are in a range from about 100 uM to about 300 uM.

In some embodiments, the method further comprises the use of apermeability enhancer. In some embodiments, the permeability enhancercomprises at least one of a non-ionic detergent, an ionic detergent, anda zwitterionic detergent. In some embodiments, the permeability enhancercomprises at least one of iontophoresis, electroporation, sonophoresis,thermal poration, microneedle treatment, and dermabrasion.

In some embodiments, the pharmaceutical formation is administeredintravenously. In some embodiments, the pharmaceutical formation isadministered intra-arterially. In some embodiments, the pharmaceuticalformation is administered orally. In some embodiments, thepharmaceutical formation is administered sublingually. In someembodiments, the pharmaceutical formation is administered transdermally.In some embodiments, the pharmaceutical formation is administered via animplantable device. In some embodiments, the pharmaceutical formation isadministered by injection. In some embodiments, the pharmaceuticalformation is administered transmucosally.

In some embodiments, the method further comprises administering a statineither simultaneously or sequentially with the pharmaceuticalformulation. In some embodiments, the pharmaceutical formulation furthercomprises the statin.

In some embodiments, there is provided a method of treatingatherosclerosis in a patient comprising: administering a pharmaceuticalformulation comprising an emulsifier in an amount effective achieve aconcentration of the emulsifier in the systemic circulation of at least50 μM at five minutes after onset of administration; wherein theconcentration of the emulsifier in the systemic circulation is sustainedabove 50 μM for a period of at least two hours; and wherein theconcentration of the emulsifier is effective to result in regression ofan atherosclerotic plaque.

In some embodiments, the sustained levels of the emulsifier in thesystemic circulation are greater than 50 μM. In some embodiments, thesustained levels of the emulsifier in the systemic circulation are in arange between about 50 μM and about 600 μM. In some embodiments, thesustained levels of the emulsifier in the systemic circulation are in arange between about 100 μM and about 300 μM.

DETAILED DESCRIPTION OF THE INVENTIONS

One approach in the treatment of atherosclerosis has been to usepharmacologic agents to interfere with the synthesis of cholesterol, acomponent of LDL, a major component of the lipid core of the plaque. Itis oxidized LDL that provides, at least in part, the primary insult tothe vessel wall that results in infiltration of monocytes, theirdifferentiation into macrophages, and the inflammatory reactions thatensues. For example, statins are now a drug of choice in the treatmentof atherosclerosis on the basis of their ability to decrease cholesterolsynthesis by interfering with the enzyme HMG-CoA reductase.

Other approaches have devised ways in which to stabilize plaques, sothat the risk of rupture and the attendant possibility of an acutecoronary event is minimized or removed. Other approaches includetreating plaque locally with anti-thrombolytics in order to prevent thecomplications due to clot formation after plaque rupture, for example asdisclosed in International Patent Application No. PCT/IN2006/000037(Chandrasekar).

Despite the relatively widespread use of statins to treatatherosclerosis, at the normally prescribed doses these compounds onlyreduce but do not eliminate the risk of acute coronary events due toatherosclerotic plaque. As a result, there remains a need to a way inwhich to reduce plaque volume in patients, in essence to reverse theprogression of atherosclerosis, by causing the regression of existingplaques.

U.S. Pat. No. 7,141,045 (Johansson et al.) discloses a method ofdissolving plaque by direct application of a dissolution fluid throughan intravascular catheter. The dissolution fluid can include a varietyof detergents, surfactants, and other solubilizing agents, in additionto enzymes, and metal ion chelators. While such an approach might beuseful for acute treatment of known atherosclerotic lesions, it isseriously limited in it utility. First, the procedure is invasive, suchthat it can only be performed by a surgeon in an operating roomsituation. This necessarily means the procedure will be costly. Second,the treatment is only effective for plaques that can be effectivelyreached by catheter, and only for plaques whose location is known wellenough by imaging techniques, such that the catheter can be guided tothe desired location. Local treatment is thus generally ineffective as asole method for the systemic treatment of atherosclerotic plaque.

As a result, there remains a need for non-invasive, systemicallyeffective compositions and treatments that we effective to result insolubilization and regression of atherosclerotic plaque, especiallysoft, or vulnerable, plaque. Results from prior studies, testing whetherstatins were effective to cause plaque regression, have been describedas equivocal. For example, in the recently completed ASTEROID study(Nissen et al., (2006), JAMA 295: 1556-1565), experiments were designedto test whether 40 mg/day of rosuvastatin would be effective to resultin a decrease in plaque volume, as evidenced by intravascular ultrasoundimaging techniques. While the treatment was particularly effective atmodulating LDL, HDL, and triglyceride levels, plaque volume after 2years was only reduced by 8.5% (SD=13.7) in the most diseased segmentsof vessels examined, and by only 6.7% (SD=11.1) with respect tonormalized total atheroma volume. Thus, statins are not particularlyeffective at producing significant reductions in plaque burden, evenwhen provided at twice the normally prescribed dosage for a period oftwo years.

Embodiments of the present invention use emulsifiers provided eithersystemically or locally to dissolve plaque and result in plaqueregression. Emulsifiers can include bile salts, saponins, and variousdetergents.

Bile acids are cholesterol-derived organic acids that have detergentproperties. Bile acids play important roles physiologically in theabsorption, transport, and secretion of lipids. These compounds havebeen characterized as primary or secondary bile acids, depending onwhether they are synthesized de novo (primary) or are derived bysubsequent chemical modification (secondary). Primary bile acids areproduced by the liver and include cholic acid(3α,7α,12α-trihydroxy-5β-cholanic acid) and chenodeoxycholic acid(3α,7α-dihydroxy-β-cholanic acid). Dehydroxylation of the primary bileacids, for example by intestinal bacteria, produces the more hydrophobicsecondary bile acids, for example deoxycholic acid(3α,12α,-dihydroxy-5β-cholanic acid), and lithocholic acid(3α-hydroxy-5β-cholanic acid). Together, the primary and secondary bileacids make up about 99% of the total bile acid pool in humans.

The role of circulating bile acid levels in the development ofatherosclerosis is not clear in the prior art. Previous studies inanimal model systems have suggested that lowering circulating levels ofbile acids through the use of bile acid sequestrants lowers LDL levelsand results in regression of atherosclerotic plaque (Wissler, J. Clin.Apher. 4: 52-58, 2006). The bile acid sequestrants colesevelam HCl hasbeen shown to reduce LDL particle number and increase LDL particle sizein patients with hypercholesterolemia (Rosenson, Atheroscl. 185:327-330, 2006). Dietary supplements comprising bile acid polymericorganic bases have been shown to inhibit cholesterol rise andatherosclerotic plaque formation in chickens on a high cholesterol diet(Tennent et al., J. Lip. Res. 1: 469-473, 1960). Thus, collectively theprior art suggests that decreasing circulating bile acid levels shouldbe effective to reduce progression, or even promote regression ofatherosclerotic plaques.

Contrary to these prior art studies, where reducing circulating levelsof bile salts is predicted to slow or regress plaque, embodiments of thepresent disclosure teach formulations and methods that lead to asustained increase in the level of emulsifiers in the systemiccirculation. These levels are effective to dissolve the lipid componentsof atherosclerotic plaque, especially vulnerable plaque, leading toplaque regression. In some embodiments, the emulsifiers comprise bileacids. In some embodiments, the emulsifiers are detergents, for example,ionic detergents, nonionic detergents, and zwitterionic detergents. Insome embodiments, the emulsifiers comprises saponins. In someembodiments, the emulsifiers comprise combinations of bile acids,detergents, and/or saponins. Experimental examples described belowdemonstrate that bile salt emulsifiers can be effective to dissolve thelips core of atherosclerotic plaque.

There are instances where the concentration of bile acids have beenincreased systemically. For example, it has been previously shown thatfeeding hyodeoxycholic acid (HDCA) to C57BL/6 LDL r-KO knockout mice(genetically predisposed to develop atherosclerosis) results in areduced rate of formation of atherosclerotic plaque relative to mice notprovided HDCA (Sehayek et al., J. Lip. Res. 42: 1250-1256, 2001). Plasmalevels of wild-type mice, provided the same amount of dietary HDCA,ranged up to about 50 μM. However, there is no evidence that theselevels were effective to result in plaque regression, as is provided bythe embodiments described herein.

Primary biliary cirrhosis (PBC) is an inflammatory disease characterizedby destruction of the small bile ducts within the liver, eventuallyleading to cirrhosis. While the cause of PBC is not precisely known, thepresence of auto-antibodies in PBC patients suggests an autoimmuneorigin. Among the various symptoms that arise as a result of PBC, it isknown that total plasma cholesterol tends to be elevated, by as much as50%. Despite the increases in cholesterol levels, however, it appearsthat PBC patients are not at an increased risk of atherosclerosis. Inaddition, it has been shown that PBC patients have elevated levels ofbile acids (Murphy et al., Gut 13: 201-206, 1972), with levels averagingabout 200 μM, as compared to normal levels which are less than 10 μM.Thus, embodiments as described herein are effective to mimic the highlevels of bile salts observed in PBC patients, and in doing so areeffective to result in regression of atherosclerotic plaque.

In general, the effective dose of a emulsifier that is effective toresult in regression of atherosclerotic plaque will vary depending on anumber of factors. Influential variable can include for example, thepatient's individual processing of bile salts or other emulsifiers inthe circulation, their personal diet and exercise regime, as well asother genetic and environmental factors. The specific optimal dosage forany particular emulsifier can vary from compound to compound, and candepend on variations in chemical properties of one emulsifier ascompared to another. For example different emulsifiers can havediffering p_(Ka) values, or solubility, which will in turn affect how apatient metabolizes the compound, how much can remain in thecirculation, and how effective the compound will be in terms ofsolubilizing the lips component of atherosclerotic plaques.

Thus in some embodiments, an effective dose will be that which issufficient to result in sustained levels of a emulsifier, for example, abile acid, of at least about 50 μM. In some embodiments, the effectivedose is sufficient to result in sustained levels of a emulsifier in arange from about 100 μM to about 600 μM. In some embodiments, theeffective dose is sufficient to result in sustained levels of aemulsifier in a range from about 100 μM to about 300 μM. By sustainedlevels, it is meant that the levels of the emulsifier are maintained inthe systemic circulation for a period of at least about 2 hours. In someembodiments, by sustained, it is meant that the levels of the emulsifierare maintained in the systemic circulation for at least 24 hours.

Examples of Bile Acid Emulsifiers

As used herein, the term “bile acid” is meant to include bile acids,pharmaceutically acceptable salts, and conjugates of bile acids, or saidsalts. Examples of bile acids useful in embodiments as described hereincan include, without limitation any naturally occurring or syntheticallyproduced bile acid, salt, or conjugate thereof, having the ability tosolubilize the lipid component of atherosclerotic plaque. This caninclude cholic acid, chenodeoxycholic acid, deoxycholic acid,lithocholic acid, ursodeoxycholic acid, hyodeoxycholic acid, and anyconjugate or pharmaceutically acceptable salt thereof.

In addition, bile acids useful in embodiments of formulation for use asdescribed herein can include, without limitation:1,3,12-trihydroxycholanoic acid; 1,3,7,12-tetrahydroxycholanoic acid;3beta-hydroxy-delta 5-cholenic acid ; 3 beta-hydroxychol-3-en-24-oicacid; 3′-isothiocyanatobenzamidecholic acid; 3,12-dihydroxy-5-cholenoicacid; 3,4,7-trihydroxycholanoic acid; 3,6,12-trihydroxycholanoic acid;3,7,12,23-tetrahydroxycholan-24-oic acid;3,7,12-trihydroxy-7-methylcholanoic acid; 3,7,12-trihydroxycoprostanicacid; 3,7,23-trihydroxycholan-24-oic acid;3,7-dihydroxy-22,23-methylene-cholan-24-oic acid (2-sulfoethyl)amide;3-((3-cholamidoρropyl)dimethylammonium)-1-propanesulfonate;3-((3-deoxycholamidopropyl)dimethylammonio)-1-propane; 3-benzoylcholicacid; 3-hydroxy-5-cholen-24-oic acid 3-sulfate ester;3-hydroxy-7-(hydroxyimino)cholanic acid; 3-iodocholic acid;7,12-dihydroxy-3-(2-(glucopyranosyl)acetyl)cholan-24-oic acid;7,12-dihydroxy-3-oxocholanic acid; allocholic acid; chapso;chol-3-en-24-oic acid; cholanic acid; sodium cholate; methyl cholate;benzyldimethylhexadecylammonium cholate; methyl1,3-dihydroxycholan-24-oate; and trioctylmethylammonium cholate); cholicacid glucuronide; cholyl-coenzyme A; cholyllysylfluorescein;cholyldiglycylhistamine; cholylhistamine; cholylhydroxamic acid;cholylsarcosine; cholyltetraglycylhistamine; ciliatocholic acid;dehydrocholic acid (which includes FZ 560; Gallo-Merz; Gillazym;Hepavis; Mexase; progresin Retard; and spasmocanulase);23-nordeoxycholic acid; 3,7-dioxocholanoic acid;3-hydroxy-ρolydeoxycholic acid; 3-sulfodeoxycholic acid;6-hydroxycholanoic acid; 6-methylmurideoxycholic acid; 7-ketodeoxycholicacid; 7-methyldeoxycholic acid; chenodeoxycholic acid;dehydrodeoxycholic acid; deoxycholyltyrosine; desoxybilianic acid;glycodeoxycholic acid; hyodeoxycholate-6-O-glucuronide; hyodeoxycholicacid; taurodeoxycholic Acid; and ursodeoxycholic acid; glycocholic acid;3-hydroxy-5- cholenoylglycine; cholylglycylhistamine;cholylglycyltyrosine; glycodeoxycholic Acid; sulfolithocholylglycine;hemulcholic acid; 12-ketolithocholic acid; 24-norlithocholic acid;3-dehydrolithocholylglycine; 3-hydroxy-6-cholen-24-oic acid;3-hydroxy-7,12-diketocholanoic acid; 3-hydroxy-7-methylcholanoic acid;3-ketolithocholic acid; 3-oxochol-4-en-24-oic acid; 3-oxocholan-24-oicacid; 4-azidophenacyl lithocholate; 7-ketolithocholic acid; BRL 39924A;glycolithocholic acid; lithocholate 3-O-glucuronide;lithocholyl-N-hydroxysuccinimide; methyl lithocholate;N-carbobenzoxy-N-lithocholyl-epsilon-lysine;N-epsilon-lithochoiyllysine; sulfolithocholic acid; and taurolithocholicacid; muricholic acid;N-(1,3,7,12-tetrahydroxycholan-24-oyl)-2-aminopropionic acid;N-(2-aminoethyl)-3,7,12-trihydroxycholan-24-amide;N-carboxymethyl)-N-(2-(bis(carboxymethyl)amino)ethyl)-3-(4-(N′-(2-((3,7,12-trihydroxycholan-24-oyl)araino)ethyl)(thioureido)ρhenyl)alanine;N-cholyl-2-fluoro-beta-alanine; norcholic acid; norursocholic acid;taurocholic acid;(N-(7-(nitrobenz-2-oxa-1,3-diazol-4-yl))-7-amino-3alpha,12alpha-dihydroxycholan-24-oyl)-2-aminoethanesulfonate;23-seleno-25-homotaurocholic acid; 3,12-dihydroxy˜7˜oxocholanoyltaurine;3-hydroxy-7-oxocholanoyltaurine; azidobenzamidotaurocholate;hexadecyltributylammonium taurocholate; tauro 1-hydroxycholic acid;tauro-3,7- dihydroxy-12-ketocholanoic acid; taurodehydrocholate;taurodeoxycholic acid; tauroglycocholic acid; taurolithocholic acid;tauromurichoUc acid; tauronorcholic acid); tetrahydroxy-5-cholan-24-oicacid; ursocholic acid; vulpecholic acid; bile acid sulfates;glycodeoxycholic acid; glycochenodeoxycholic acid;7-oxoglycochenodeoxycholic acid; glycochenodeoxycholate-3-sulfate;glycohyodeoxycholic acid; tauro-7,12-dihydroxycholanic acid;taurochenodeoxycholic acid; taurochenodeoxycholate-3-sulfate;taurochenodeoxycholate-7-sulfate; tauroursodeoxycholic acid;taurohyodeoxycholic acid; the includes: 23-methylursodeoxycholic acid;24-norursodeoxycholic acid; 3,6-dihj^(?)droxy-6-methylcholanoic acid;3,7-dihydroxy-20,22- methylenecholan-23-oic acid;3,7-dihydroxy-22,23-methylenecholan-24-oic acid;3,7-dihydroxy-7-ethylcholanoic acid; 3,7-dihydroxy-7-methylcholanoicacid; 3,7-dihydroxy-7-n-propylcholanoic acid; Bamet-UD2;diammhiebis(ursodeoxycholate(O,O′))ρIatinum(II); glycoursodeoxycholicacid; homoursodeoxycholic acid; HS 1030; HS 1183; isoursodeoxycholicacid; PABA-ursodeoxycholic acid; sarcosylsarcoursodeoxycholic acid;sarcoursodeoxycholic acid; ursodeoxycholate-3-sulfate; ursodeoxycholicacid 7-oleyl ester; ursodeoxycholic acid N-acetylglucosaminide;ursodeoxycholic acid-3-O-glucuronide; ursodeoxycholylN-carboxymethylglycine; ursodeoxycholylcysteic acid; ursometh;24-norchenodeoxycholic acid; 3,7-dihydroxy-12-oxocholanoic acid;3,7-dihydroxy-24-norcholane-23-sulfonate;3,7-dihydroxy-25-homocholane-25-sulfonate; 3,7-dihydroxychol-5-enoicacid; 3,7-dihydroxycholane-24-sulfonate; 3-glucosido-chenodeoxycholicacid; 3-oxo-7-hydroxychol-4-enoic acid; 6-ethylchenodeoxycholic acid;chenodeoxycholate sulfate conjugate; chenodeoxycholyltyrosine;glycochenodeoxycholic acid which includes: 7-oxoglycochenodeoxycholicacid and glycochenodeoxycholate-3-sulfate; homochenodeoxycholic acid; HS1200; methyl 3,7-dihydroxychol-4-en-24-oate; methyl3,7-dihydroxycholanate; N-(2-aminoethyl)-3,7-dihydroxycholan-24-amide;N-chenodeoxycholyl-2-fluoro-beta-alanine; sarcochenodeoxycholic acid;taurochenodeoxycholic acid; taurochenodeoxycholate-3-sulfate;taurochenodeoxycholate-7-sulfate; tauroursodeoxycholic acid.

Examples of Saponin Emulsifiers

In some embodiments, saponins are provided as emulsifiers. Saponins arenaturally occurring compounds predominantly derived from plants andwhich have detergent properties. The name saponin is derived from thesoapwort plant (Saponaria) traditional used in the making of a type ofsoap. Saponins are the glycosides of 27 carbon steroids or 30 carbontriterpenes. Removal of the sugar moiety from a saponin by hydrolysisyields the aglycone, sapogenin. Triterpenoid saponins are generallyacid, while steroid saponins are generally neutral.

Steroid saponins include three classes of compounds, the cholestanol,furostanol, and spirostanol saponins. Examples of furostanol saponinscan include, protoisoeruboside-B and isoeruboside-B, as well as saponinsderived, for example, from Ruscus aculeatus, Tacca chantrieri, Solanumhispidum, Dioscorea polygonoides, Tribulus terrestris, and Liliumcandidum. Other steroid saponins can include those derived fromSaponaria officinalis, Yucca schidigera, and Chlorogalum pomeridianum.

Examples of triterpenoid saponins can include those of thefusidane-lanostante group, cyclopassiflosides, cycloglobiseposides,cycloartanes, dammaranes (e.g., bacopasaponin and jujubogenin), lupanes(e.g., quadranosides), oleananes (e.g., maesapinin), ligatosides,sandrosaponins, pedunsaponins), vulgarsaponin, peduncularisaponin,petersaponin, araliasaponin, assamsaponin, eupteleasaponin,herniariasaponin, jeosaponin, meliltussaponin, ursanes (e.g.,randisaponins), brevicuspisaponin, ursolic acid, and indicasaponin.Triterpenoids can also be derived from Quillaja saponaria, as well asthose derived from grapes.

Saponins have been identified in plants and animals including, forexample, and without being limiting, agave, alfalfa, aloe, Anadenantheraperegrine, amaranth, Angelica sinesis, Aralia chinesis, Araliamanshurica, asparagus, Astragalus membranaceus, Bacopa monnieri,Boussingaultia sp., Bupleurum chinense, Calendula officinalis, Capsicumsp., chickweed, Chlorophytum sp., Chlorogalum sp., Codonopsis pilosula,horse chestnuts, curcurbit, Digitalis sp., Echinodermata, Elecampane,Elutherococcus senticosus, fenugreek, goldenrod, gotu kola, grape skin,Gymnema sylvestre, Gypsophila sp., hawthorn, jiaogulan, licorice,lungwort, mullein, olives, onion, pannax (Koren Ginseng), Platycodongrandiflorum, Polygala tenuifola, Quillaja saponaria, quinoa, Phytolaccaamericana, rambutan, Salvia sp., soapberry, Saponaria sp., Schizandrachinensis, shallots, southern pea, soybean, Tribulus terrestris, wildyam, yucca, and Zizyphus jujube.

Examples of Detergents

Various detergents are useful as emulsifiers in embodiments as describedherein, including ionic detergents, nonionic detergents, andzwitterionic detergents. Detergents can be used to augment or enhancethe effectiveness of other emulsifiers such as bile acids and/orsaponins. Detergent can also be used as permeability enhancers,effective to enhance the permeability of membranes or tissue toemulsifiers.

Examples of Routes of Administration

Various routes of administration of emulsifiers can be used, forexample, and without being limiting, by injection, transdermally,orally, by inhalation, and transmucosally. In some embodiments,emulsifiers can be perfused directly into the systemic circulation byway of an implantable pump. Regardless of the route of administration,the dosing of emulsifiers will result in achieving sustained levels ofan emulsifier in the systemic circulation that are effective to resultin plaque regression.

In some embodiments, formulations comprise a sustained releaseformulation that results in the maintenance of circulating levels ofemulsifiers that are effective to result in plaque regression. In someembodiments, formulations can comprise a sustained release deliverysystem can be used to deliver the emulsifier such that increased levelsare achieved for extended periods of time, for example, a period of 2hours or longer. In some embodiments, release is sustained over a periodof 24 hours. In some embodiments, a sustained release delivery systemcan further comprise one or more pharmaceutical diluents known in theart. Exemplary pharmaceutical diluents include, without limitation,monosaccharides, disaccharides, polyhydric alcohols and a combinationthereof. In some embodiments, pharmaceutical diluents can include, forexample, starch, lactose, dextrose, mannitol, sucrose, microcrystallinecellulose, sorbitol, xylitol, fructose, a combination thereof.

In some embodiments, the pharmaceutical diluent can be water-soluble,for example, lactose, dextrose, mannitol, sucrose, and a combinationthereof. In some embodiments, the sustained release delivery system cancomprise one or more pharmaceutical diluents in an amount of about 5% toabout 80% by weight; from about 10% to about 50% by weight; or about 20%by weight of a dosage form.

In some embodiments, a emulsifier delivery system can comprise one ormore hydrophobic polymers. The hydrophobic polymers can be used in anamount sufficient to slow the hydration of the active ingredients. Forexample, the hydrophobic polymer can be present in the sustained releasedelivery system in an amount of about 0.5% to about 20% by weight; in anamount of about 2% to about 10% by weight; in an amount of about 3% toabout 7% by weight; or in an amount of about 5% by weight.

Embodiments of formulations as described herein can be admixed with oneor more wetting agents (e.g., polyethoxylated castor oil,polyethoxylated hydrogenated castor oil, polyethoxylated fatty acid fromcastor oil, polyethoxylated fatty acid from hydrogenated castor oil, ora combination thereof) one or more lubricants (e.g., magnesium stearate,sodium stearyl fumarate), one or more glidants (e.g., silicon dioxide),one or more buffering agents, one or more colorants, and/or otherconventional ingredients well known to those of skill in the art ofpharmaceutical compounding.

In some embodiments, a sustained release coating can comprise at leastone water insoluble compound, for example, a hydrophobic polymer. Thehydrophobic polymer can be the same as or different from the hydrophobicpolymer used in the sustained release delivery system. Exemplaryhydrophobic polymers include, without being limiting, alkyl celluloses(e.g., C₁₋₆ alkyl celluloses, carboxymethylcellulose), other hydrophobiccellulosic materials or compounds (e.g., cellulose acetate phthalate,hydroxypropylmethylcellulose phthalate), polyvinyl acetate polymers(e.g., polyvinyl acetate phthalate), polymers or copolymers derived fromacrylic and/or methacrylic acid esters, zein, waxes (alone or inadmixture with fatty alcohols), shellac, hydrogenated vegetable oils,and a combination thereof. In some embodiments, the hydrophobic polymercan comprise methyl cellulose, ethyl cellulose, propyl cellulose or amixture of two or more thereof. In another embodiment, the hydrophobicpolymer is ethyl cellulose. The compositions of the invention can becoated with a water insoluble compound to a weight gain from about 1 toabout 20% by weight.

Formulation can be coated with a sustained release coating that canfurther comprise at least one plasticizer such as triethyl citrate,dibutyl phthalate, propylene glycol, polyethylene glycol, or mixtures oftwo or more thereof. A sustained release coating can also contain atleast one water soluble compound, such as polyvinylpyrrolidones,hydroxypropylmethylcelluloses, and mixtures thereof.

A sustained release coating can be applied to a core comprising one ormore emulsifiers by spraying an aqueous dispersion of the waterinsoluble compound onto core. The core can be a granulated compositionmade, for example, by dry or wet granulation of mixed powders ofemulsifiers and at least one binding agent; by coating an inert beadwith emulsifiers and at least one binding agent; or by spheronizingmixed powders of emulsifiers and at least one spheronizing agent. Someexemplary binding agents include hydroxypropylmethylcelluloses.Exemplary spheronizing agents can include microcrystalline celluloses.The inner core can be a tablet made by compressing the granules or bycompressing a powder comprising emulsifiers and/or pharmaceuticallyacceptable salts or conjugates thereof.

In some embodiments, the compositions comprising emulsifiers and asustained release delivery system, as described herein, are coated witha sustained release coating, as described herein. In some embodiments,the compositions comprising emulsifiers and a sustained release deliverysystem, as described herein, are coated with a hydrophobic polymer, asdescribed herein. In some embodiments, the compositions comprisingemulsifiers and a sustained release delivery system, as describedherein, are coated with an enteric coating. Exemplary enteric coatingsinclude, without being limiting, cellulose acetate phthalate,hydroxypropylmethylcellulose phthalate, polyvinylacetate phthalate,methacrylic acid copolymer, shellac, hydroxypropylmethylcellulosesuccinate, cellulose acetate trimelliate, and a combination thereof.

In some embodiments, the compositions comprising an emulsifier and asustained release delivery system, as described herein, are coated witha hydrophobic polymer, as described herein, and further coated with anenteric coating. In any of the embodiments described herein, thecompositions comprising emulsifiers and a sustained release deliverysystem, as described herein, can optionally be coated with a hydrophiliccoating which can be applied above or beneath a sustained release film,above or beneath the hydrophobic coating, and/or above or beneath theenteric coating. Exemplary hydrophilic coatings includehydroxypropylmethylcelluloses.

Formulations can further comprise agents to enhance absorption acrossthe intestinal epithelium. These can include, without being limiting,other emulsifiers or detergents, some of which are listed above, EDTA,sodium salicylate, sodium caprate, diethyl maleat,N-lauryl-β-D-maltophyranoside, linoleic acid polyoxyethylated, tartaricacid, SDS, Triton X-100, hexylglucoside, hexylmaltoside,heptylglucoside, octylglucoside, octylmaltoside, nonylglucoside,nonylmaltoside, decylglucoside, deceylmaltoside, dodecylmaltoside,tetradecylmaltoside, dodecylglucoside, tridecylmaltoside, as well asmucolytic agents, for example N-acetylcysteine and chitosan.

Where a transdermal route is selected, the formulation can furthercomprise one or more permeability enhancers, effective to increase therate of movement of the emulsifier across the epithelium and into thesystemic circulation. Permeability enhancers can include, for example,sulfoxides, alcohols, fatty acids and fatty acid esters, polyols,surfactants, terpenes, alkanones, liposomes, ethosomes, cylodextrins. Insome embodiments permeability enhancers include, without being limiting,ethanol, glyceryl monoethyl ether, monoglycerides, isopropylmyristate,lauryl alcohol, lauric acid, lauryl lactate, lauryl sulfate, terpinol,menthol, D-limonene, DMSO, polysorbates, N-methylpyrrolidone,polyglycosylated glycerides, Azone®, CPE-215®, NexAct®, SEPA®, andphenyl piperizine.

In some embodiments other methods of administration across an epitheliumcan be used, for example, iontophoresis, electroporation, sonophoresis,thermal poration, microneedle treatment, and dermabrasion.

In some embodiments, the pharmaceutical formulation is administered soas to achieve circulating levels of at least 50 μM of the emulsifierwithin 5 minutes after administration. In some embodiments,administration is performed intravenously. In some embodiments,administration occurs intra-arterially. In some embodiments, levels in arange from about 50 μM to about 600 μM are achieved within 5 minutes ofadministration. In some embodiments, levels in a range from about 100 μMto about 600 μM are achieved within 5 minutes of administration. In someembodiments, levels in a range from about 100 μM to about 300 μM areachieved within 5 minutes of administration.

Combinations of Emulsifiers and Statins

In some embodiments, a method of treating a patient having, or suspectedof having, atherosclerotic plaques can include treatment with anemulsifier as described above, in combination with agents that areeffective to lower cholesterol. For example, the class of compoundsknown as “statins” are effective to lower cholesterol. Statins areinhibitors of HMG-CoA reductase, the rate limiting enzyme in thesynthesis of mevalonate, a key intermediate in the synthesis ofcholesterol, from acetyl-CoA.

A variety of natural and synthetic statins are known. These include, forexample and without being limiting, atorvastatin, cerivastatin,fluvastatin, lovastatin, mevastatin, pitavastatin, pravastatin,rosuvastatin, and simvastatin. Therefore, in some embodiments, a methodof treating atherosclerosis, effective to result in a reduction inplaque volume can comprise treatment with an emulsifier as describedabove effective to achieve a level of the administered emulsifier in thesystemic circulation, greater than about 50 uM, in combination with astatin. In some cases, the statin can be administered at a dosage of 20mg/day; in some cases the statin can be administered at a dosage of 40mg/day. The statin and emulsifier can be administered concurrently, orsequentially. In some embodiments, the statin and emulsifier can beprovided in the same pharmaceutical composition, either as a mixture orin sub-compartments of a single dosage form such as a pill, capsule,injectable, or any other suitable form for administration.

In some embodiments, emulsifiers can be administered in combination witha statin and an agent effective to control blood pressure. For example,in some cases emulsifiers can be provided simultaneously, orsequentially, with a statin and a compound like amlodipine.

Emulsifiers, as well as other therapeutic compounds, for example,statins, can be administered by way of a stent. In some embodiments,after an angioplasty procedure, a stent comprising at least oneemulsifier as described above, can be placed in a vessel at the site ofthe angioplasty. The stent is configured to release the emulsifiers in asustained fashion, such that a local concentration that is effective todissolve plaques is achieved. The stent can be loaded with one or moreemulsifiers, and/or additional therapeutic compounds, and configured torelease the therapeutic ingredients over an extended period of time. Insome embodiments, the local concentration of emulsifier provided by thestent can be greater than 50 μM. In some embodiments, the localconcentration of emulsifier can be in a range from about 50 μM to about600 μM. In some embodiments, the local concentration of the emulsifiercan range from about 100 μM to about 300 μM. Emulsifier eluting stentscan be of a balloon-expandable design, or self-expanding. The stent canalso include additional agents effective to dissolve plaque, forexample, ionic detergents, nonionic detergents, and zwitterionicdetergents. An exemplary list of detergents is provided in InternationalApplication PCT/US2007/001214, the entire contents of which areincorporated by reference herein.

In some embodiments, a stent can further comprise enzymes that willdigest other components of the plaque (e.g., the fibrous cap), forexample proteolytic enzymes such as collagenase, Pronase, Proteinase K,trypsin, chymotrpysin, and other proteases well known to those in theart. Proteases can be selected from classes of proteases including, andwithout being limiting, serine proteases, threonine proteases, cysteineproteases, aspartic acid proteases, metalloproteases, and glutamic acidproteases. As such, the enzymes listed are understood to be merelyexemplary and not exhaustive of the enzymes that can be included in astent configured for sustained release of emulsifiers. Proteolyticenzymes that are effective to dissolve blood clots, can also be usefulin embodiments of stents that release emulsifiers, in order to prevent,or at least limit, the risk of forming a thrombus at or near the sitewhere the stent is placed in the patient. A stent can also include othertherapeutic agents such as anti-inflammatory compounds, or compoundsthat are effective to promote healing of the vessel.

EXPERIMENTAL EXAMPLES

In vitro experiments were performed to test the ability of deoxycholicacid (DCA) to solubilize atherosclerotic plaque material. In theseexperiments, ex vivo samples of pig artery were bathed in an aqueoussolution at two different concentrations of DCA. In the firstexperiment, samples were treated with 50 mg/mL DCA for successiveperiods of 30 minutes, at which time the sample was removed from thebathing medium, and the appearance of the plaque examinedmacroscopically. Early in the treatment, on removal of the sample fromthe bath a clear, viscous, column of fluid extended from the sample.This column of fluid continued to be apparent when samples wereevaluated up to about 4 or 5 hours, after which the fluid column was nolonger noted. Without wishing to be held to any one theory of operation,it was concluded that the clear fluid comprised components of theplaque.

After 5 hours of treatment with DCA, macroscopic assessment of plaquesize suggested that plaque volume had decreased by about 70%. After 36hours of exposure all that appeared to remain of plaques were thefibrous cap material and areas of calcification. All core materialappeared to have been solubilized.

In a second experiment, atherosclerotic plaque in a sample of pig arterywas exposed to a continuous flow of a solution of 0.25 mg/mL DCA,diluted in normal saline (approximately 600 μM DCA). The sample wascontinuously exposed for a period of 8 days. Macroscopic examination ofthe sample at this time revealed that most, if not all, of the lipidcore of the plaque had been solubilized, and all that remained was thefibrous cap.

In both experiments, treatment with DCA caused no obvious detrimentaleffects on the vessel itself. In particular, elasticity of the vesselwall appeared unaffected. While not wishing to be held to any one theoryof operation, sustained levels of an emulsifier are demonstrated by thisexample to be effective to produce regression of atherosclerotic plaque,apparently by dissolving the lipid components of the plaque, which oncesolubilized cross the fibrous cap into the surrounding milieu. In apatient, it is expected that solubilized lipid liberated from plaques bythe administered emulsifiers, will be released into the blood streamwhere they can be metabolized and eliminated from the body by normalphysiological routes, for example, by excretion in the bile as freecholesterol, or by conversion to bile acids in the liver.

The skilled artisan will recognize the interchangeability of variousfeatures from different embodiments. Similarly, the various features andsteps discussed above, as well as other known equivalents for each suchfeature or step, can be mixed and matched by one of ordinary skill inthis art to perform compositions or methods in accordance withprinciples described herein. Although the disclosure has been providedin the context of certain embodiments and examples, it will beunderstood by those skilled in the art that the disclosure extendsbeyond the specifically described embodiments to other alternativeembodiments and/or uses and obvious modifications and equivalentsthereof. Accordingly, the disclosure is not intended to be limited bythe specific disclosures of embodiments herein.

1. A method, of treating atherosclerosis in a patient, comprising:administering, across an epithelium of a patient, a pharmaceuticalformulation comprising an emulsifier; enhancing a permeability of theepithelium to the emulsifier with a permeability enhancer; whereinenhancing the permeability of the epithelium is effective to result inpassage of the emulsifier across the epithelium and into the patient'ssystemic circulation; wherein the passage of the emulsifier across theepithelium results in sustained levels of the emulsifier in thepatient's systemic circulation that are therapeutically effective toresult in regression of an atherosclerotic plaque.
 2. The method ofclaim 1, wherein the emulsifier comprises at least one of a bile acid, asaponin, a detergent, or pharmaceutically acceptable salts, conjugates,hydrates, solvates, polymorphs, or mixtures thereof.
 3. The method ofclaim 1, wherein the emulsifier comprises a bile acid, orpharmaceutically acceptable salts, conjugates, hydrates, solvates,polymorphs, or mixtures thereof.
 4. The method of claim 2, wherein thesustained levels of the emulsifier in the systemic circulation aregreater than 50 μM.
 5. The method of claim 2, wherein the sustainedlevels of the emulsifier in the systemic circulation are in a rangebetween about 50 μM and about 600 μM.
 6. The method of claim 2, whereinthe sustained levels of the emulsifier in the systemic circulation arein a range between about 100 μM and about 300 μM.
 7. The method of claim2, wherein the emulsifier comprises deoxycholic acid.
 8. The method ofclaim 7, wherein the sustained levels of the deoxycholic acid in thesystemic circulation are greater than 50 μM.
 9. The method of claim 7,wherein the sustained levels of the deoxycholic acid in the systemiccirculation are in a range between about 50 μM and about 600 μM.
 10. Themethod of claim 7, wherein the sustained levels of the deoxycholic acidin the systemic circulation are in a range between about 100 μM andabout 300 μM.
 11. The method of claim 2, wherein the emulsifiercomprises a mixture of ursodeoxycholic acid and deoxycholic acid insubstantially equimolar amounts.
 12. The method of claim 2, wherein theemulsifier comprises hyodeoxycholic acid.
 13. The method of claim 12,wherein the sustained levels of the hyodeoxycholic acid in the systemiccirculation are greater than about 50 uM.
 14. The method of claim 12,wherein the sustained levels of the hyodeoxycholic acid in the systemiccirculation are in a range from about 50 uM to about 600 uM.
 15. Themethod of claim 12, wherein the sustained levels of the hyodeoxycholicacid in the systemic circulation are in a range from about 100 uM toabout 300 uM.
 16. The method of claim 1, wherein the permeabilityenhancer comprises at least one of a non-ionic detergent, an ionicdetergent, and a zwitterionic detergent.
 17. The method of claim 1,wherein the permeability enhancer comprises at least one ofiontophoresis, electroporation, sonophoresis, thermal poration,microneedle treatment, and dermabrasion.
 18. The method of claim 1,wherein the pharmaceutical formation is administered intravenously. 19.The method of claim 1, wherein the pharmaceutical formation isadministered intra-arterially.
 20. The method of claim 1, wherein thepharmaceutical formation is administered orally.
 21. The method of claim1, wherein the pharmaceutical formation is administered sublingually.22. The method of claim 1, wherein the pharmaceutical formation isadministered transdermally.
 23. The method of claim 1, wherein thepharmaceutical formation is administered via an implantable device. 24.The method of claim 1, wherein the pharmaceutical formation isadministered by injection.
 25. The method of claim 1, wherein thepharmaceutical formation is administered transmucosally.
 26. The methodof claim 1, further comprising administering a statin eithersimultaneously or sequentially with the pharmaceutical formulation. 27.The method of claim 18, wherein the pharmaceutical formulation furthercomprises the statin.
 28. A method of treating atherosclerosis in apatient comprising: administering a pharmaceutical formulationcomprising an emulsifier in an amount effective achieve a concentrationof the emulsifier in the systemic circulation of at least 50 μM; whereinthe concentration of the emulsifier in the systemic circulation issustained for a period of at least two hours; wherein the concentrationof the emulsifier is effective to result in regression of anatherosclerotic plaque.
 29. The method of claim 28, wherein theemulsifier comprises at least one of a bile acid, a saponin, adetergent, or pharmaceutically acceptable salts, conjugates, hydrates,solvates, polymorphs, or mixtures thereof.
 30. The method of claim 28,wherein the emulsifier comprises a bile acid, or pharmaceuticallyacceptable salts, conjugates, hydrates, solvates, polymorphs, ormixtures thereof.
 31. The method of claim 29, wherein the sustainedlevels of the emulsifier in the systemic circulation are greater than 50μM.
 32. The method of claim 29, wherein the sustained levels of theemulsifier in the systemic circulation are in a range between about 50μM and about 600 μM.
 33. The method of claim 29, wherein the sustainedlevels of the emulsifier in the systemic circulation are in a rangebetween about 100 μM and about 300 μM.
 34. The method of claim 29,wherein the emulsifier comprises deoxycholic acid.
 35. The method ofclaim 34, wherein the sustained levels of the deoxycholic acid in thesystemic circulation are greater than 50 μM.
 36. The method of claim 34,wherein the sustained levels of the deoxycholic acid in the systemiccirculation are in a range between about 50 μM and about 600 μM.
 37. Themethod of claim 34, wherein the sustained levels of the deoxycholic acidin the systemic circulation are in a range between about 100 μM andabout 300 μM.
 38. The method of claim 29, wherein the emulsifiercomprises a mixture of ursodeoxycholic acid and deoxycholic acid insubstantially equimolar amounts.
 39. The method of claim 29, wherein theemulsifier comprises hyodeoxycholic acid.
 40. The method of claim 39,wherein the sustained levels of the hyodeoxycholic acid in the systemiccirculation are greater than about 50 uM.
 41. The method of claim 39,wherein the sustained levels of the hyodeoxycholic acid in the systemiccirculation are in a range from about 50 uM to about 600 uM.
 42. Themethod of claim 39, wherein the sustained levels of the hyodeoxycholicacid in the systemic circulation are in a range from about 100 uM toabout 300 uM.
 43. The method of claim 28, further comprising using apermeability enhancer.
 44. The method of claim 43, wherein thepermeability enhancer comprises at least one of a non-ionic detergent,an ionic detergent, and a zwitterionic detergent.
 45. The method ofclaim 28, wherein the permeability enhancer comprises at least one ofiontophoresis, electroporation, sonophoresis, thermal poration,microneedle treatment, and dermabrasion.
 46. The method of claim 28,wherein the pharmaceutical formation is administered intravenously. 47.The method of claim 28, wherein the pharmaceutical formation isadministered intra-arterially.
 48. The method of claim 28, wherein thepharmaceutical formation is administered orally.
 49. The method of claim28, wherein the pharmaceutical formation is administered sublingually.50. The method of claim 28, wherein the pharmaceutical formation isadministered transdermally.
 51. The method of claim 28, wherein thepharmaceutical formation is administered via an implantable device. 52.The method of claim 28, wherein the pharmaceutical formation isadministered by injection.
 53. The method of claim 28, wherein thepharmaceutical formation is administered transmucosally.
 54. The methodof claim 28, further comprising administering a statin eithersimultaneously or sequentially with the pharmaceutical formulation. 55.The method of claim 54, wherein the pharmaceutical formulation furthercomprises the statin.
 56. A method of treating atherosclerosis in apatient comprising: administering a pharmaceutical formulationcomprising an emulsifier in an amount effective achieve a concentrationof the emulsifier in the systemic circulation of at least 50 μM at fiveminutes after onset of administration; wherein the concentration of theemulsifier in the systemic circulation is sustained above 50 μM for aperiod of at least two hours; and wherein the concentration of theemulsifier is effective to result in regression of an atheroscleroticplaque.
 57. The method of claim 56, wherein the sustained levels of theemulsifier in the systemic circulation are greater than 50 μM.
 58. Themethod of claim 56, wherein the sustained levels of the emulsifier inthe systemic circulation are in a range between about 50 μM and about600 μM.
 59. The method of claim 56, wherein the sustained levels of theemulsifier in the systemic circulation are in a range between about 100μM and about 300 μM.